Agenda Setting and Policy Adoption of India's National Health Insurance Scheme: Rashtriya Swasthya Bima Yojana

Rashtriya Swasthya Bima Yojana (RSBY) is India's largest health insurance scheme. Launched in 2007, it now covers over 37 million, mostly poor, families. This massive scheme represents a major departure from past approaches to government support for health care in India. In this article, we use data from key informant interviews, published and unpublished documents, and newspaper reports, applying Kingdon's framework for agenda setting and policy adoption to explain how RSBY became national policy. India's government-operated health care delivery system had consistently failed to meet its most basic objectives-especially for the poor. A variety of previous reform efforts had been unsuccessful. Then, in 2004, the result of the national election was seen by the victors as representing a mandate to address deprivation among those in India's vast unorganized sector. That election also brought to the fore a new set of policy makers who were willing to introduce subsidized health insurance that made extensive use of the private sector. Technological advancements offered the reformers both new options and new experiences on which to base their innovations. A group of policy entrepreneurs, including Congress Party leaders, technocrats, and senior government officials, collaborated with international agencies to develop the RSBY approach, place it on the agenda, and assure its adoption as national policy. This analysis explores factors that made this significant equity-oriented health reform possible in India and provides lessons for health reformers in other countries who seek to learn from India's experiences in moving toward universal health coverage. Finally, we suggest some adjustments in Kingdon's framework to help apply his ideas in different contexts.